PERMIT DOCUMENTS . / 2 - 2 Ika
o`or City of Boynton Beach
Building Division
INSTALLATION AFFIDAVIT
WINDOW & DOOR (replacement)
To: City of Boynton Beach, Florida
Department of Development- Building Division
Field Inspection Section
100 East Boynton Beach Blvd., PO Box 310
Boynton Beach,h,FL 33425-0310/ the r
Re: Permit No. 1 )00001.. e
From: So /0.9 rein Wt'lLl1„>..,15 ` DOUbtS (Contractor)
1-.50 1/4) ,.) 33 CA- SuIA-c 1B (Contractor's Address)
LiAk , 034ll (,J u-k 1W_ (Owner/s Name)
1k37 S W `l' Scht-C-F (Property Address)
TIFICATION SELECTION: (Please check all that apply)
edification of Window Installation
Certification of Door Installation
Other (glass block, etc)
//��,
I, IT'taa - 0v. P.iW- 0 , am a licensed contractor (license No.
CUL 152_0 ZS ff ) and do hereby certify that all work (as indicated above) has been performed and
installed at the above address in accordance with the Florida Building Code, Existing Building, as amended,
and Manufacturer's Installation Instructions/NOA/ Product Approvals submitted.
�� 11 171 11
:ignatu - o • •- ifier Date
STATE OF FLORIDA, COUNTY OF PALM BEACH
The foregoing instrument was acknowledged before me this i/, Si / �"" 77-444; )
J
I fr (date)by 4U� 1'Jal 7I w7-q , who
is persionelly known to mr who has produced (type of identification)as identification
and who did(did not)take an oath. cL�(t!C C c L S.
EAL)
Signature of person taking acknowledgementfiteIV V. Stela lame ro
J (�_ NOTARY PUBLIC
Name of officer taking acknowledgement-typed, printed or stamped 57e/4 (C0:')Q( G =K: -STATE OF FLORIDA
1 (( • 1-o Corm*00048411
Title or rank 4141 Serial number 66 o4/g 11
• Expires 11/16/2020
100 East Boynton Beach Blvd, PO Box 310,Boynton Beach FL 33425-0310 Phone:(561)742-6350 Fax: (561)742-6357
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